PHARMACISTS

We're here to help answer your questions about member eligibility and benefit plan information, claims processing, and payment/remittance questions.

(888) 832-2779

Available 24/7 including holidays

For any legal or clinical information, please send to:

Capital Rx Attn: Prior Authorization
9450 SW Gemini Dr., #87234, Beaverton, OR 97008

Forms & Documents

Pharmacy Provider Manual



Capital Rx Provider Manual is a guide for network pharmacies that includes policies and procedures including, but not limited to, contact information, term definitions, claims processing information and pharmacy network participation requirements.

Last updated: November 2022

Download PDF

Reversal Payer Sheet



Reversal Payer sheets provide data requirements needed to electronically process NCPDP pharmacy claim reversals for each line of business within Capital Rx. Each line of business will have a designated reversal payer sheet for reference when a pharmacy chooses to reverse claims submitted to Capital Rx from their pharmacy system.
‍
Last updated: October 2021

Download PDF

Electronic Remittance Advice Enrollment



If you have questions regarding your pharmacy remittance advice, please outreach to ap@cap-rx.com.

Click Here

Prior Authorization Request Form



To submit a prior authorization (if required), please complete the prior authorization request form and fax it (along with any additional documentation required) to (833) 434-0563.

Prior authorization request forms can also be sent via mail to the below address:
Capital Rx
Attn: Prior Authorization
9450 SW Gemini Dr., #87234
Beaverton, OR 97008

Download PDF

Payer Sheet



Payer sheets provide data requirements needed to electronically process NCPDP pharmacy claims for each line of business within Capital Rx. Each line of business will have a designated payer sheet for reference when setting up Capital Rx BIN/PCN numbers into the pharmacy system.

Last updated: January 2023

Download Commercial PDF Download Medicare PDF

Electronic Funds Transfer (EFT) Enrollment Form



If you have questions regarding your pharmacy payments please reach out to ap@cap-rx.com.

Click Here

Direct Member Reimbursement Form



Please call us at (888) 832-2779 and our support team will work with you to validate the member's eligibility.

Download PDF

Formulary Look-Up (Open/Freedom)



Please call us at (888) 832-2779 and our support team will work with you to validate the member's eligibility.

Click Here

Formulary Look-Up (Closed/Liberty)



Please call us at (888) 832-2779 and our support team will work with you to validate the member's eligibility.

Click Here

Explore pharmacist resources

Our number one priority is ensuring the health and safety of our members through access to over 65,000+ retail pharmacies.

Pharmacy Help Desk Services

Join our Pharmacy Network

Payment or Remittance Questions

Frequently Asked Questions

What BIN number is used to adjudicate claims?



Our BINs 610852 and 610770 adjudicate on Capital Rx's platform. For additional information on these BINs, please consult the payer sheet for Capital Rx.

What do I do if I cannot confirm a member's eligibility?



Please call us at (888) 832-2779 and our support team will work with you to validate the member’s eligibility. If for any reason the issue cannot be resolved in real-time, please suggest that the patient pay for the prescription upfront and, once the eligibility error has been corrected, submit a paper claim to us. DMR form can be found here.

What should I do if a member thinks that his/her out-of-pocket obligation is incorrect?



Please call us at (888) 832-2779 to verify the patient pay amount.

Who do I contact for payment/remittance questions?



Please send your questions to ap@cap-rx.com.

What do I do if a claim rejects?



Please call us at (888) 832-2779 and our support team will work with you to resolve the rejection as quickly as possible.

How long does a prior authorization review take?



Most prior authorization reviews are completed within two business days provided that a complete prior authorization request form and all required documentation are correctly submitted. Our clinical team will notify you in advance of any declinations and assist in expediting your patient to a preferred alternative therapy.

How can I join the Capital Rx pharmacy network?



To join our network, please contact us at provider.relations@cap-rx.com.